Vol. 68, No. 3
Briefs
253
Physician, Can You Justify Your Job Description? GLEN G. CAYLER, M.D., Director, Cardiopulmonary Diagnostic Center, Sutter Hospitals, Sacramento, California
The job description for a physician states that his purpose is to save life before threat of death and preserve life for the living. All physicians accept this job description not only as a noble and worthy calling, but also as a job whose importance for our planet no one questions. To question whether our mission of preserving life is important and necessary, at first seems incredulous, shocking, and ridiculous. But after all, all life is mortal. This we know incontrovertibly, so in what sense can it be said to be a matter of special importance if mankind itself ultimately perishes? Does man have some special quality that makes him something more than the other products of nature? That is the essential question. The answer is that man, unlike other living creatures, cries out for justice and right. The rest of nature's products are not just and not humane, but essentially "tooth and claw". Man's plea for justice and right separates man from animal and represents the deepest cry within man's being and justifies man's claim to being nature's most important creation. Man, alone, knows that good ought to be and injustice ought not to be. This dedication to good and justice is the primary creed of the human race and unites us to a common moral purpose. Why have we struggled so long trying to define more completely the human purpose? We all know that hatred, cruelty, intolerance, and indifference to human misery are evil and that love, kindliness, tolerance, forgiveness and truth are good. We do not need God to assure us of this axiom, virtue is self-evident. If men's lives were loving and honorable and if we were, in fact, kind, forgiving, and truthful, there would be no problems of an urgent or serious kind in the world today. I believe we can agree that our common human purpose (bond) is our crying out for justice and right, but even though the distinction between good and evil is self-evident, man, after millennia of struggle, shows as yet but faint signs of overcoming evil. Men are so incapable of acting because we are not reared with a sense of the importance of an active obligation to what is right and just. We are taught that the real purpose of life is to be successful, as the world measures success in our age. Virtue is something that is largely left to take care of itself. One does as his neighbors do and as his professional standards require, and no one can pretend that such requirements are his very special own. In spite of this, it is interesting that among teachers,
soldiers, churchmen, criminals, housewives, police, workmen, politicians, and physicians, it is rare to meet someone who is essentially an evil person. It appears that evil occurs in a world of essentially no evil men. The problem seems to be that few men are able to act upon the voice of their conscience and, particularly, men of influence and position, who have powers to lose, for inevitably the price of conscience is a growing ineligibility for promotion to positions of authority and influence. Men, it seems, cannot have both power over others and genuine love for others. In brief, although human beings are equipped to distinguish good from evil, there is a price to be paid for choosing the good rather than the evil and most men are not willing to pay that price. Therefore, it is not enough to know that kindliness is good and cruelty is bad. It is also necessary to know why we are alive and what is the purpose of the life temporarily entrusted to us. Every man must be bound by some conviction, conscious or unconscious, about the significance he attaches to his life in order to live it, to direct it, to make plans or merely to drift. Men's behavior reveals the real values sustaining their lives, and this metaphysic is the most important thing that we must know of a man to assess his basic character or to project how he will act in a given situation. Most individuals find the meaning of their life not only in self-indulgence, but in satisfying the wants of their group or groups with which they identify emotionally. The most universal form of ego identification with a group is the family, but the principle extends to schools, villages, churches, and political parties. The trouble with "goods" sought for one's self or one's group is that they are exclusive. They displace a like good for somebody else or some other group. They are not compatible with the principle of universalism and, therefore, violate the principle of justice. They stimulate competition. They are thus the very stuff of strife, of envy, of the struggle for power, of the resentments of inferiority and of the war of all against all. Unfortunately, the energies which are harnessed to these secular goals are very powerful and sustain the central efforts of most men's lifetime struggle. What would happen if man rejected these values as having morally indefensible consequences to mankind as a whole? To what, then, would a man devote his energies? What would be the central goal of his life? If he ceased to find his purpose in the quest for power,
254
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
privilege, status, authority and wealth, what substitute is there that is morally acceptable and which can realistically evoke a comparable single-mindedness and consistently sustain application of energy? No matter what the answer, the first step consists in renouncing what we have hitherto heen dedicated to. Such a renouncement is very difficult for man as most men do not wish to be really known as individuals. This holds even when one realizes that his health and salvation depend on such a knowledge. He does not even wish to be known by himself and refuses to be his own witness. Additionally, not only do we have to overcome the resistances within ourselves, but we must overcome our fears of the resistance of those among whom we live. To follow the voice of truth is difficult because of our instinctive awareness that to do so will not simply fail to add to our popularity, but may evoke strong resistance from those around us. If Christ were to live on earth today, people would break his windows! But even though it is difficult to acknowledge the truth and to follow it, it is not impossible. To do what I will, may not always lie within my power. But what surely does lie within my power is the ability to will the good. It is peculiar and unique power of truth that if acknowledged freely and honestly, ultimately it will of its own accord rectify our existing false situation. Truth is a hard taskmaster, for it demands that the first step in its service be willingness to transcend the planes of the self in the service of other selves. The problem is that insofar as a man succeeds in his aspiration to obey truth, he inevitably puts himself at the mercy of all who suffer from no such inhibitions and who accordingly take advantage of him. Even so, there is no other way in which man can be taught the truth, for if to avoid defeat, we resist evil violently, we provide yet another alibi for wrong doing. Many see only that a battle of wills is taking place and they understand that well enough from long familiarity. It is essential to show that we struggle, not that our will should prevail, but that the truth of justice and equality should prevail. But what confidence can be have in the presence of so much violence in our vast surrounding ocean of evil? Faith? Yes, perhaps, but not blind faith-it must be reasonable faith based on evidence and reasoning conducted as always by rigorous adherence to the logic of the argument to the end. After all, if we are to have faith it may well cost us our lives! It is inescapable that so long as one man survives who is willing to take advantage of his physically weaker brother, our earth will remain as a kingdom of power. But might it not be that an unknown factor could, if found, trusted, and relied upon, ultimately prevail over the forces of power? But what if this factor becomes efficacious only if we trust it even on to
MAY, 1976
possible acceptance of a violent, premature and otherwise inescapable death? And if such a factor is found by all trustable experience to exist, a factor before which power itself is rendered impotent by non-power means, what name must we give it? Love! But what is the power of love? Its great strength turns out to be its powerlessness. When we attain the natural naive humility of the child, it is then and only then, when power has fled us completely, that ultimately we move even the most hardened. Jesus is not remembered for his successes, but what captured the imagination of the world for two millennia is a man who taught "resist not evil" and "God forgive them, for they know not what they do." And indeed it is the case-we do not know. We do not really know what it is we do, or we could not inflict such astonishing and unbelievable cruelties on one another. But the "tough-minded" will say that whatever truth there is in the foregoing will have done nothing to demonstrate that ethics is not an autonomous discipline. The true form of conduct consists in finding the meaning of one's life, not in the quest for wealth, power, and prestige, but engaging in activities prompted by consideration of the needs of one's fellows. This conduct does not come naturally and easily to man, but the meaning of every individual's life consists in the choice which he, of necessity, is required to make between these two alternatives. Why should the individual choose the good when it is a path full of difficulties and pitfalls and which may lead him into a position of discomfort, hardship, persecution, and even peril to his life? Why should I prefer good to my own immediate comfort? Even if I am capable of willing the good, why should I? For good is not the will of the rest of nature, whose fruit is one that is indeed read in tooth and claw. Then why should I obey this will? Whose will is it? It is the common will of all men, their deepest spiritual meaning. We know that if we sow not love, we reap not love and our soul withers. When we try to sow love, it matters not if we succeed or fail; for when we fail in our moralistic strivings, we are humbled and that is good for us. When we succeed, we are not comforted, but threatened by our pride; and that is also good. So we know that nature can be conquered by the spirit, but will we do it? We must all make our own individual decision. There can be no other way. Do you hear a cry from your deepest inner spirit, "good ought to be and injustice out'not to be"? Are you living the creed of this voice? So, fellow physicians, we can justify our purpose to save and preserve human life; but we must add an addendum to the sign on our office door, "physician working here-my job is to help to heal your ills and to (Concluded on page 252)
252
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
MAY, 1976
A Different Surgical Approach For Carpal Tunnel Syndrome* RAYMOND 0. PIERCE, M.D., Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
We present here a different surgical approach for the decompression of the median nerve in carpal tunnel syndrome. This approach provides excellent exposure and avoids hypertrophic scars in patients subject to keloid formation. The traditional S shaped incision or the transverse incision have their disadvantages." 2 The transverse incision does not allow visualization of the distal portion
Fig. 1. Surgical approach for carpal tunnel syndrome.
of the transverse ligament and the S shaped incision is apt to cause a hypertrophic scar. The present approach consists of a transverse incision at the wrist and a curved incision parallel to and on the ulnar side of the thenar crease (Fig. 1). *Read at the 79th Annual Convention of the National Medical Association New Orleans, Louisiana, August, 1974.
After the transverse incision is made, the skin and subcutaneous tissue are undermined, both proximally and distally. The proximal portion of the transverse carpal ligament and median nerve are identified. The transverse carpal ligament is then divided on the ulnar side of the median nerve, proceeding distally until obscured by the distal skin flap. The palmar skin incision is then made, leaving a bridge of skin of about one centimeter between the incisions. Subcutaneous tissue is dissected to the distal portion of the transverse carpal ligament. A hemostat is inserted ulnar to the median nerve under the transverse ligament from the proximal to the distal incision. The remaining transverse carpal ligament is then cut under direct vision. The motor branch of the median nerve can be explored and decompressed if necessary. The use of these two incisions for decompression of the median nerve avoids subsequent scar problems associated with the lazy-S incision in patients prone to keloid formation and provides better visualization of the median nerve than the transverse incision. LITERATURE CITED
1. BRUNER, J. M. Incisions for Plastic and Reconstructive (Non-Septic) Surgery of the Hand. Brit. J. Plastic Surgery, v. 4, p. 48, 1951. 2. BUNNELL, S. Plastic Problems in the Hand; Plastic Reconstructive Surgery, v. 1, p. 266, 1946.
(Cayler, from page 254)
help preserve your life and I hope that in so doing both both of us will live our lives with greater joy and happiness and with a larger concern for our fellow men." There is only one catch, and this may be a "Catch 22", if doing your job doesn't give you joy and more concern for the welfare of your fellow men, you must consider the possibility that the job as a physician may not be the correct and best position for you.
Briefs
253
Physician, Can You Justify Your Job Description? GLEN G. CAYLER, M.D., Director, Cardiopulmonary Diagnostic Center, Sutter Hospitals, Sacramento, California
The job description for a physician states that his purpose is to save life before threat of death and preserve life for the living. All physicians accept this job description not only as a noble and worthy calling, but also as a job whose importance for our planet no one questions. To question whether our mission of preserving life is important and necessary, at first seems incredulous, shocking, and ridiculous. But after all, all life is mortal. This we know incontrovertibly, so in what sense can it be said to be a matter of special importance if mankind itself ultimately perishes? Does man have some special quality that makes him something more than the other products of nature? That is the essential question. The answer is that man, unlike other living creatures, cries out for justice and right. The rest of nature's products are not just and not humane, but essentially "tooth and claw". Man's plea for justice and right separates man from animal and represents the deepest cry within man's being and justifies man's claim to being nature's most important creation. Man, alone, knows that good ought to be and injustice ought not to be. This dedication to good and justice is the primary creed of the human race and unites us to a common moral purpose. Why have we struggled so long trying to define more completely the human purpose? We all know that hatred, cruelty, intolerance, and indifference to human misery are evil and that love, kindliness, tolerance, forgiveness and truth are good. We do not need God to assure us of this axiom, virtue is self-evident. If men's lives were loving and honorable and if we were, in fact, kind, forgiving, and truthful, there would be no problems of an urgent or serious kind in the world today. I believe we can agree that our common human purpose (bond) is our crying out for justice and right, but even though the distinction between good and evil is self-evident, man, after millennia of struggle, shows as yet but faint signs of overcoming evil. Men are so incapable of acting because we are not reared with a sense of the importance of an active obligation to what is right and just. We are taught that the real purpose of life is to be successful, as the world measures success in our age. Virtue is something that is largely left to take care of itself. One does as his neighbors do and as his professional standards require, and no one can pretend that such requirements are his very special own. In spite of this, it is interesting that among teachers,
soldiers, churchmen, criminals, housewives, police, workmen, politicians, and physicians, it is rare to meet someone who is essentially an evil person. It appears that evil occurs in a world of essentially no evil men. The problem seems to be that few men are able to act upon the voice of their conscience and, particularly, men of influence and position, who have powers to lose, for inevitably the price of conscience is a growing ineligibility for promotion to positions of authority and influence. Men, it seems, cannot have both power over others and genuine love for others. In brief, although human beings are equipped to distinguish good from evil, there is a price to be paid for choosing the good rather than the evil and most men are not willing to pay that price. Therefore, it is not enough to know that kindliness is good and cruelty is bad. It is also necessary to know why we are alive and what is the purpose of the life temporarily entrusted to us. Every man must be bound by some conviction, conscious or unconscious, about the significance he attaches to his life in order to live it, to direct it, to make plans or merely to drift. Men's behavior reveals the real values sustaining their lives, and this metaphysic is the most important thing that we must know of a man to assess his basic character or to project how he will act in a given situation. Most individuals find the meaning of their life not only in self-indulgence, but in satisfying the wants of their group or groups with which they identify emotionally. The most universal form of ego identification with a group is the family, but the principle extends to schools, villages, churches, and political parties. The trouble with "goods" sought for one's self or one's group is that they are exclusive. They displace a like good for somebody else or some other group. They are not compatible with the principle of universalism and, therefore, violate the principle of justice. They stimulate competition. They are thus the very stuff of strife, of envy, of the struggle for power, of the resentments of inferiority and of the war of all against all. Unfortunately, the energies which are harnessed to these secular goals are very powerful and sustain the central efforts of most men's lifetime struggle. What would happen if man rejected these values as having morally indefensible consequences to mankind as a whole? To what, then, would a man devote his energies? What would be the central goal of his life? If he ceased to find his purpose in the quest for power,
254
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
privilege, status, authority and wealth, what substitute is there that is morally acceptable and which can realistically evoke a comparable single-mindedness and consistently sustain application of energy? No matter what the answer, the first step consists in renouncing what we have hitherto heen dedicated to. Such a renouncement is very difficult for man as most men do not wish to be really known as individuals. This holds even when one realizes that his health and salvation depend on such a knowledge. He does not even wish to be known by himself and refuses to be his own witness. Additionally, not only do we have to overcome the resistances within ourselves, but we must overcome our fears of the resistance of those among whom we live. To follow the voice of truth is difficult because of our instinctive awareness that to do so will not simply fail to add to our popularity, but may evoke strong resistance from those around us. If Christ were to live on earth today, people would break his windows! But even though it is difficult to acknowledge the truth and to follow it, it is not impossible. To do what I will, may not always lie within my power. But what surely does lie within my power is the ability to will the good. It is peculiar and unique power of truth that if acknowledged freely and honestly, ultimately it will of its own accord rectify our existing false situation. Truth is a hard taskmaster, for it demands that the first step in its service be willingness to transcend the planes of the self in the service of other selves. The problem is that insofar as a man succeeds in his aspiration to obey truth, he inevitably puts himself at the mercy of all who suffer from no such inhibitions and who accordingly take advantage of him. Even so, there is no other way in which man can be taught the truth, for if to avoid defeat, we resist evil violently, we provide yet another alibi for wrong doing. Many see only that a battle of wills is taking place and they understand that well enough from long familiarity. It is essential to show that we struggle, not that our will should prevail, but that the truth of justice and equality should prevail. But what confidence can be have in the presence of so much violence in our vast surrounding ocean of evil? Faith? Yes, perhaps, but not blind faith-it must be reasonable faith based on evidence and reasoning conducted as always by rigorous adherence to the logic of the argument to the end. After all, if we are to have faith it may well cost us our lives! It is inescapable that so long as one man survives who is willing to take advantage of his physically weaker brother, our earth will remain as a kingdom of power. But might it not be that an unknown factor could, if found, trusted, and relied upon, ultimately prevail over the forces of power? But what if this factor becomes efficacious only if we trust it even on to
MAY, 1976
possible acceptance of a violent, premature and otherwise inescapable death? And if such a factor is found by all trustable experience to exist, a factor before which power itself is rendered impotent by non-power means, what name must we give it? Love! But what is the power of love? Its great strength turns out to be its powerlessness. When we attain the natural naive humility of the child, it is then and only then, when power has fled us completely, that ultimately we move even the most hardened. Jesus is not remembered for his successes, but what captured the imagination of the world for two millennia is a man who taught "resist not evil" and "God forgive them, for they know not what they do." And indeed it is the case-we do not know. We do not really know what it is we do, or we could not inflict such astonishing and unbelievable cruelties on one another. But the "tough-minded" will say that whatever truth there is in the foregoing will have done nothing to demonstrate that ethics is not an autonomous discipline. The true form of conduct consists in finding the meaning of one's life, not in the quest for wealth, power, and prestige, but engaging in activities prompted by consideration of the needs of one's fellows. This conduct does not come naturally and easily to man, but the meaning of every individual's life consists in the choice which he, of necessity, is required to make between these two alternatives. Why should the individual choose the good when it is a path full of difficulties and pitfalls and which may lead him into a position of discomfort, hardship, persecution, and even peril to his life? Why should I prefer good to my own immediate comfort? Even if I am capable of willing the good, why should I? For good is not the will of the rest of nature, whose fruit is one that is indeed read in tooth and claw. Then why should I obey this will? Whose will is it? It is the common will of all men, their deepest spiritual meaning. We know that if we sow not love, we reap not love and our soul withers. When we try to sow love, it matters not if we succeed or fail; for when we fail in our moralistic strivings, we are humbled and that is good for us. When we succeed, we are not comforted, but threatened by our pride; and that is also good. So we know that nature can be conquered by the spirit, but will we do it? We must all make our own individual decision. There can be no other way. Do you hear a cry from your deepest inner spirit, "good ought to be and injustice out'not to be"? Are you living the creed of this voice? So, fellow physicians, we can justify our purpose to save and preserve human life; but we must add an addendum to the sign on our office door, "physician working here-my job is to help to heal your ills and to (Concluded on page 252)
252
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
MAY, 1976
A Different Surgical Approach For Carpal Tunnel Syndrome* RAYMOND 0. PIERCE, M.D., Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
We present here a different surgical approach for the decompression of the median nerve in carpal tunnel syndrome. This approach provides excellent exposure and avoids hypertrophic scars in patients subject to keloid formation. The traditional S shaped incision or the transverse incision have their disadvantages." 2 The transverse incision does not allow visualization of the distal portion
Fig. 1. Surgical approach for carpal tunnel syndrome.
of the transverse ligament and the S shaped incision is apt to cause a hypertrophic scar. The present approach consists of a transverse incision at the wrist and a curved incision parallel to and on the ulnar side of the thenar crease (Fig. 1). *Read at the 79th Annual Convention of the National Medical Association New Orleans, Louisiana, August, 1974.
After the transverse incision is made, the skin and subcutaneous tissue are undermined, both proximally and distally. The proximal portion of the transverse carpal ligament and median nerve are identified. The transverse carpal ligament is then divided on the ulnar side of the median nerve, proceeding distally until obscured by the distal skin flap. The palmar skin incision is then made, leaving a bridge of skin of about one centimeter between the incisions. Subcutaneous tissue is dissected to the distal portion of the transverse carpal ligament. A hemostat is inserted ulnar to the median nerve under the transverse ligament from the proximal to the distal incision. The remaining transverse carpal ligament is then cut under direct vision. The motor branch of the median nerve can be explored and decompressed if necessary. The use of these two incisions for decompression of the median nerve avoids subsequent scar problems associated with the lazy-S incision in patients prone to keloid formation and provides better visualization of the median nerve than the transverse incision. LITERATURE CITED
1. BRUNER, J. M. Incisions for Plastic and Reconstructive (Non-Septic) Surgery of the Hand. Brit. J. Plastic Surgery, v. 4, p. 48, 1951. 2. BUNNELL, S. Plastic Problems in the Hand; Plastic Reconstructive Surgery, v. 1, p. 266, 1946.
(Cayler, from page 254)
help preserve your life and I hope that in so doing both both of us will live our lives with greater joy and happiness and with a larger concern for our fellow men." There is only one catch, and this may be a "Catch 22", if doing your job doesn't give you joy and more concern for the welfare of your fellow men, you must consider the possibility that the job as a physician may not be the correct and best position for you.
